July 11, 2025 • 34 mins
Join us on the AHF Podcast as host Joe Schwab sits down with Dr. Chris Johnson, a leading orthopedic oncology surgeon and president of Orthopedics Northeast. Based in Fort Wayne, Indiana, Dr. Johnson shares his extensive experience and insights on treating metastatic acetabular disease using the anterior approach. Learn about his background, the evolution of surgical techniques, and the benefits and challenges of using the anterior approach in complex oncology cases. This episode offers valuable information for orthopedic professionals and highlights advancements that can improve patient outcomes in orthopedic oncology.
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Episode Transcript
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Joseph M. Schwab (00:23):
Hello and welcome to the A HF Podcast.
I'm your host, Joe Schwab.
Today we're joined by Dr.
Chris Johnson, an orthopediconcology surgeon and leader in
complex adult reconstruction.
Dr.
Johnson serves as president ofOrthopedics Northeast, one of
the largest private orthopedicpractices in the Midwest, and
(00:43):
he's based in Fort Wayne,Indiana.
He's also the co-director of theOrtho Northeast Adult
Reconstruction FellowshipProgram and the chair of
orthopedic oncology at theParkview Pacnet Family Cancer
Institute.
Dr.
Johnson has extensive clinicalexpertise in anterior total hip
arthroplasty, complex revisionarthroplasty and orthopedic
(01:06):
oncology.
He not only brings a uniqueperspective to the management of
complex acetabular pathology.
He's an advocate for usinganterior approach for cases
thought to require other typesof exposures.
Today he joins us to discuss anuanced but increasingly
important topic, treatingmetastatic acetabular disease
(01:28):
and doing it through theanterior approach.
Dr.
Johnson, welcome to the A HFPodcast.
Chris Johnson (01:35):
Hey Joe, thanks for having me, excited to be
here, should be fun.
Joseph M. Schwab (01:38):
So tell me a little bit about your background
and maybe a little bit aboutyour current practice setting.
It sounds interesting.
Chris Johnson (01:45):
sure.
I'm, uh, I'm originally fromMichigan and did residency and
Michigan State University andthen did my orthopedic oncology
fellowship at the University ofWashington Medical Center in
Seattle.
And then it came to OrthopedicsNortheast, uh, to start my
practice and, uh, my.
Focus was really on oncology tostart and we built a sarcoma
program and orthopedic oncologyprogram there then our group has
(02:09):
a very high volume jointreplacement center and we're
doing a lot of complex revisionsand sort of disaster plasticity
type cases.
So we started adultreconstruction fellowship as
well.
So I do a lot of jointreplacement and revision as well
as oncology work.
And, um, on the primary side, Ido a lot of anterior hips.
So kind of blending the oncologyside revision side with the
(02:30):
anterior approach.
Joseph M. Schwab (02:31):
Wow.
And so what, uh, what led you toexplore really the use of
anterior approach in sort ofmanaging oncologic conditions?
Chris Johnson (02:42):
well, I was exposed to a lot of anterior
approach and residency, and, um,you know, patients do great.
And then in my own practice, youknow, I have my sort of anterior
primary side, which is reallyquite nice.
You know, quick surgeries,patients go home same day often,
and, uh, outcomes are great.
And then, you know, of course, Ihave the oncology side, and,
and, and, uh, things are morecomplex and challenging.
(03:02):
But the outcomes of anteriorhips are so good, it was, it's
just very natural to startblending that into, uh, more
complex problems.
Joseph M. Schwab (03:10):
Did you find any unique challenges that came
with, um, the orthopediconcology patient population and
anterior approach?
Or did it, was it a prettyseamless transition?
Chris Johnson (03:22):
I.
would say it was kind of anatural progression.
We start, you know, classicallyacid tabular metastatic defects
are taking care of with, youknow, what was called a
Harrington reconstruction, whereyou make multiple incisions, you
open up the ileum and pelvisside.
You also make a second incisionto do a, uh, you know, posture
approach or lateral approach,and then you reconstruct the
acetabulum with some Steinmanpins, and it was a pretty
(03:44):
invasive surgery.
You're taking down abductors.
Sometimes it's a big surgeryand, um, required a lot of
thought.
Once, um, David Geller's groupin the Bronx, they, they
described the tripod techniquefor acetabular defects.
And that really was a gamechanger for us, because once we
started doing that, we have, youknow, a nice multidisciplinary
team.
In our trauma service, westarted doing percutaneous
(04:05):
screws for some more simpleacetabular defects.
And then the natural progressionof the world, if we're doing
these percutaneous screws, it'snot very invasive.
Why don't we do an answer yourapproach with that and start
doing that for some of our askedother mastectomies.
And so we started with smallercases and build it up to even,
you know, you know, bigchallenging cases.
And the answer your approachworks.
Well, we basically now doingmetastatic disease without
(04:25):
cutting any muscle.
Maybe we'll play it, peel offthe TFL off the helium if we
need a cage or something bigger.
Um, but, you know, the patientsare up and walking and a six
weeks.
It's almost like a primary hipfor some of these patients, A
big change from what we weredoing with, you know, more
classic Harrington typereconstructions.
Joseph M. Schwab (04:43):
And let's talk a little bit about how these
patients sort of present oneswho are coming with, you know,
metastatic disease that's aroundthe acetabulum.
How is that?
I mean, how are, how are theygonna end up in your clinic?
What are you gonna see?
What are they gonna tell you?
Chris Johnson (04:58):
Yeah, I mean, they come from all over the
place, generally have a lot ofpain, that's how it was
discovered.
You know, so they generally haveinguinal pain, similar to an
arthritic patient.
You're going to have groin painor inguinal pain because the hip
joint is, is, is, um, you know,having problems.
And then they'll come in frommedical oncology, they'll come
in from other orthopedic doctorsall over the place.
And then, um, Each case isunique, you know, the size of
(05:19):
the defect, the primary cancer,whether it's lymphoma versus
renal cell, two totallydifferent things.
Renal cell can be much morechallenging, bleeding,
progression of disease, um, orother things like prostate
cancer, breast cancer.
Breast cancer can be moresensitive to radiation, so
really the specific diagnosis isvery important to which type of
(05:40):
metastatic disease it is.
Um, and then once they, oncethey present and we have them,
we really, we get advancedimaging like a CT scan to sort
of see the 3D defect to thenplan ahead of how we're gonna,
if we need to, how we're goingto reconstruct it.
Joseph M. Schwab (05:54):
Mm-hmm.
And so how do you decide on whoyou're gonna operate?
Uh, you know, who's a goodcandidate for surgery for this
particular surgery?
Chris Johnson (06:03):
I mean, AST is a, challenging problem and
generally should requiremultidisciplinary approach,
medical oncology, radiationoncology, orthopedic oncology,
I'm a big believer in informeddecision making, talking to the
patients and family, giving themthe risk and benefits of each
scenario.
And these are big surgeriesshould be last resort.
If you can get away withradiation or non operative
things first, certainlyreasonable to try, but I would
(06:25):
say anecdotally, in my practice,we've got a little more
aggressive of surgery becausewe're doing an anterior
approach.
We're doing percutaneous screws.
It's not as big of a dealanymore.
And so we can be a little moreaggressive with getting surgery
done and people are happy andyou know, they, they get up and
walking.
All these patients come in, theyare non ambulatory, cannot walk
at all severe pain.
You know, many of them arewalking the day of surgery.
(06:45):
And so.
Um, but informant says you'remaking it a little more
challenges than a primary hip orrevision hip because you have to
deal with chemotherapy.
They're probably, you know,higher host.
See, basically, they're onchemotherapy.
They're immunocompromised andthen fixation, you know, we
can't utilize horse metal asmuch because we may not have
good in growth, which you canwith TM in certain scenarios,
(07:07):
but you're usually more cementand cement fixation compared to
a standard revision.
So a little bit unique in thatregard.
Joseph M. Schwab (07:15):
So it sounds like anterior, the using
anterior approach has allowedyou to sort of expand your
surgical indications in thispopulation at least a little
bit.
Chris Johnson (07:23):
think so.
I think for me personally, I wasa little more conservative with
a more classic Harringtonapproach because it was such a
big surgery.
We really, you know, it takestime to heal.
Someone has metastatic lungcancer, for example, and maybe
their prognosis, their lifespan,maybe a year or less, and
they're going to spend three tofour months recovering.
It's like, I don't know.
You know, what is worth?
What's the appropriate boundary?
Again, family discussion withthe anti approach.
(07:45):
You know, we're getting themhealing faster.
It's a little quicker.
You know, in 6 weeks, I feellike they're usually generally
pretty happy and doing prettyrelatively well.
So you can get him healedquicker so that you have to
worry as much about the timelinedecision making.
Joseph M. Schwab (08:01):
So when somebody shows up, I'm, I'm
really familiar with whensomebody shows up with arthritis
in their hip, I know what thegoals of my operation are gonna
be.
I mean, I, I, I know I want toget them back up and
functioning, get'em playingpickleball, get'em playing golf,
doing all those sorts of things.
When you're treating these typesof lesions in the
Chris Johnson (08:19):
hmm.
Joseph M. Schwab (08:20):
um, are, are your primary surgical goals
different?
What are you looking to achieve?
Chris Johnson (08:27):
That's a great question.
The really the primary focus oftreating anybody with menistic
disease, whether it's in theacetabulum, the femur anywhere
is immediate weight bearing.
Ambulation and function, becausethese patients may have a
shorter lifespan.
You want to get them going.
They're often gettingchemotherapy.
So if they're stuck in a bed forsix weeks, it's not very good.
So they need to be up andwalking to tolerate chemotherapy
(08:49):
and subsequent treatments andalso quality of life.
So the main goal is immediateweight bearing.
Unlike some revision scenarioswhere you may.
You know, let's say like a, uh,pelvic discontinuity and maybe
you're doing a tri-flange.
You might protect their weightbearing for a little while.
Let's try to get ingrowth in theimplant, etc.
In this case, we don't reallyhave that time.
We don't have that luxury oftime, so we gotta get immediate
(09:10):
weight bearing right away.
So that's the big difference, Iwould say, is we want to allow
for immediate ambulation.
So cement fixation in certainscenarios and, and try and get
them going.
Joseph M. Schwab (09:20):
And so let's talk a little bit about the
technique.
I mean, you mentioned the tripodtechnique.
Tell me a little bit, can yougimme a brief description of
what it, what it is, what itlooks like?
Chris Johnson (09:30):
so the tripod technique is much.
It's really the percutaneousscrews for acetabular fractures.
It's really originally describedby the trauma world um, then
when David Geller's group kindof combined it brought to the
ortho oncology world, which is,you know, a great concept.
I showed it to some of ourtrauma colleagues and say, Hey,
(09:50):
can you guys do this?
And they're like, Yeah, we dothis all the time for geriatric
patients.
Falls and fractures and like,okay, well, let's let's start
doing with these and I'm luckyto have a great team.
So, um, our trauma service isvery good doing per screws.
So we started doing them andthey do them in like 30 minutes.
I mean, it's really quick andeasy.
They basically get certainspecific views.
You're basically putting screwsthrough the poster column.
(10:14):
anterior column and then the LC2screw like in the trauma world.
So you're really creating atripod to reinforce the
acetabulum similar to what aHarrington reconstruction is
doing by putting K wires downthrough the ileum trying to
basically rebarb the acetabulumto put cement into it.
This is doing the same thing,but with three small incision
percutaneous incisions underfluoroscopic guidance.
(10:37):
And you're basically puttinglong screws that go into good
bone through the You know, thecancer and defect into good bone
again because they're longscrews and that allows a less
invasive, quick and precise wayto or rebarb the acetabulum to
allow for subsequent andoriginally described for just
(10:58):
the screws only.
But you could.
I think the original study had20 patients, but they said you
could augment or, you know,convert to a total hip easily.
And so we started doing screwswith the tripod technique, and
then in cases who had a lot ofdefects around the acetabulum,
then, then adding, adding in atotal hip.
And we started with posteriorapproach, because that's what I
was comfortable doing in morecomplex things.
And as I went on, we evolved tothe
Joseph M. Schwab (11:20):
So when you're actually doing the
reconstruction, they've gottheir screws in place.
Um, are, are they doing any, sofirst of all, um, when they're
getting their screws put in, arethey doing any percutaneous
cement application at the sametime or just the screw?
Chris Johnson (11:35):
you could in cases in which there are
different products out therewhere you could put screws that
have cement.
We have not been doing it.
And some places do describethat.
That's certainly an option.
What we typically do if it's ifit's a screw only case, we put
the screws in and see how theydo.
If it's screws and total hip, weput the screws in and then I'll
open it up to the anteriorapproach.
And it really depends again.
(11:57):
Each case is different where thedefect is, what type of cancer
it is.
We open up through an antiapproach.
What's obviously nice about theanti approach is the S tablet
exposures.
So nice.
There's a pine easy X ray youcan see the tablet really,
really well.
So it's just so convenient.
And then we'll remove the tumor,because these are more
palliative cases, we're notdoing a wide excision, we're
(12:18):
doing intralesional excisions,removing the bone, often burr
down to help, to, as best wecan, down to normal bone, so
you, then you see the remainingdefect.
And then at that case, youusually have a pretty good idea
going into the size, if there'sdiscontinuity, etc.
Do you need to augment with thecage?
Are you just doing the bigshell?
Are you cementing it?
We do a lot of, um, you know,cemented dual mobility liners,
(12:40):
where we just cement them in anddo that anteriorly.
Um, if we need constraint ornot, you know, do they have, you
know, sometimes they need a PFR,maybe the proximal femur is
gone.
So really each case is unique,assessing where the defects are,
what the challenges are, and howyou're gonna, you know,
reconstruct it most optimally.
Joseph M. Schwab (12:57):
So, um, we actually got introduced through,
um, a mutual acquaintance thatwe know at at Johnson Johnson, j
and j Med Tech.
DePuy Synthes, Johnson andJohnson.
Um, are those the implantsystems that you typically use,
or what are, what kind ofconstructs are you typically
using?
It's okay to use brand names ifyou want to.
It's, uh, you just, or are youusing a variety of, uh, of
(13:19):
items?
Chris Johnson (13:21):
used a variety.
I have used a lot of J&J.
Thank you.
Um, they're, um, Bimentum Cup, Iuse a lot.
I think it's very, very, so I'm,you know, do a lot of J&J
anterior hips.
The actus is a great stem, soit's super easy.
And we're using their valusnavigation with these two.
So it's another thing comparedto poster approach Harrington
where you're trying to, youknow, imagine putting a cup in
(13:42):
with a huge hole.
I mean, it is, no one can bethat precise at but you get to
do it on the anterior perchunder fluoro.
I'm putting in a cemented cupunder, under VHN or under
navigation assistance forprinting these cuffs in a
pretty, you know, relativelyprecise way.
So because of all that, I tendedto use the J&J, Bimentum, which
(14:03):
is a cemented single dualmobility liner, and then I just
do the femur like normal, andthen it's pretty simple.
we have you some like a cage hasbecome less, less common.
A lot of companies are gettingrid of cages, which would prefer
they didn't because I understandthat in a revision setting where
(14:24):
you're trying to get on growthmakes sense.
You know, porous metals, customimplants, augments, all that
stuff makes total sense in astandard revision.
Aseptic loosening, you're tryingto get osseo integration.
So the implants last in thecancer world, you don't
necessarily have that.
You don't have the luxury oftime.
So, cages can help, certainly,oncology cases because you can,
(14:45):
you do the tripod to help getrid of discontinuity, reinforce
the acetabulum, but then you canbridge the defect even more so
if there's more massive boneloss with, um, with some cages.
And so, um, we have used SmithNephew for certain cases because
they still have a decent, nicecage system.
So, depending on what I need,I'll adjust.
Joseph M. Schwab (15:05):
Yeah.
Um, and I was gonna ask, I mean,because most of these, because
this patient populationspecifically, you're talking
about metastatic disease aroundthe acetabulum, you're able to
use a, a pretty standard primarystem.
I mean, you mentioned the Actisstem, right?
It, it's, most of the timeyou're gonna be putting in
something fairly basic likethat.
Chris Johnson (15:25):
a really good question.
So I think that's somethingthat's not been studied well,
and it's a little anecdotal.
Historically, in the oncologyworld, you cement everything
and, you know, someone has apristine femur, but has
acetabular menistic disease.
Do you need to cement the femur?
I don't know.
I mean, they might getradiation.
So, will the radiation impactthe young growth on the femoral
(15:46):
side?
Is there a higher risk ofloosening?
Because they get radiation, evenif they have no disease there?
Of course if they have diseasein the bone, in the femur, I'm
gonna cement.
But if they have a pristine,normal femur, I haven't
breastfed anymore because, um,know, I haven't had a lot of
problems with loosening theactive.
I have a lot of experience withthe active stem and a triple
(16:07):
taper stem.
It works well and there is somerisk, you know, B.
C.
I.
S.
Bone implant syndrome.
You know, people always talkabout should you cement or not
in the in the primary settingand all these things.
But in my mind, this is just myperspective.
You know, how many fractureswould you accept?
Or how many loosenings would youaccept for one catastrophic
(16:27):
BCIS?
And so, in the oncology world,we cement more, and I have seen,
you know, a handful of patientshave problems with cementing.
It is a big deal.
And so, if you can get away withpress fitting, I think it's, it
works well.
So, I have been more and moreaggressive in my practice with
press fitting a standard stem insomeone who has metastatic
disease in the last tabulum, andhaven't really had any problems
Joseph M. Schwab (16:48):
So you've mentioned some of the advantages
that at least you've seen inbeing able to do some of this
through an anterior approach.
Are there any technicalchallenges that you run into in
this patient population orexposure?
Uh, exposure challenges forthese more complex
reconstructions.
Chris Johnson (17:05):
think on the acetabular side, it's honestly
easier.
Um, when I compare, I think partof it is the experience thing,
and just the fear.
When you do something new in alearning curve, you're worried
about making mistakes and doingsomething wrong.
And as you get through practice,you start to gain confidence and
try, you know, just try to bereasonable and do the right
thing.
(17:25):
When I compare it to doing a,say, a Tri-Flandre custom
implant on a revision settingand a post-G approach, I think
it's a lot easier.
And which we've done quite a bitof those and have good
experience with that.
It's still, there's still somechallenges exposing the ileum
without hurting the abductors,all those things.
With the anti-approach, you'resupine, you can peel off the
TFL, and you can expose thewhole ileum extremely easily.
(17:48):
And then repairs really nicely,you repair it right back to the
top of the ileum.
It's a really nice exposure.
I think, I remember we weredoing, once we were starting to
think about these things, wewere doing a course for J&J
actually, and we had someFellows with us and we were
doing just some cadaver labs andwe were exploring like, can we
really do a tri flangeinteriorly?
Can we put cages on interiorly?
(18:09):
And it was so easy and I waslike, it was for me.
I was a big confidence boosterbecause I was trying to teach
people what to do, but I wasreally experimenting myself and
I'm like, wow, I can, I can putmy finger in this attic notch
and feel the bottom of theissue.
It's really easy.
I mean, if you extend theincision approximately over the
iliac brim and then peel off theTFL, it's one big sleeve and the
(18:29):
whole lateral pelvis is rightthere.
It's pretty remarkable.
Joseph M. Schwab (18:33):
Yeah, that's, uh, so how do you go about, you
mentioned actually usingintraoperatively, using ves for
cup positioning and things likethat, or, you know, using some
sort of intraoperative uh,technology.
How do you plan for these cases?
What, I mean, what, what are youusing to, to come up with your,
I'm assuming there's plans Athrough Z right?
Chris Johnson (18:54):
Yeah, we're, I mean, we're lucky that we have
an institution where we haveeverything on the shelf.
So, I mean, I pretty much, Idon't have to worry too much.
And we have we're busy and sothe teams are used to what we're
doing.
We're not doing it's not newevery time.
But yes, no doubt.
You have to plan for everything.
Um, I'm a planner.
I like to think ahead.
And, um, but yes, sort of astepwise approach where the
(19:16):
defects their discontinuity.
the cancer, what's the primarydiagnosis?
Renal cell versus breast versusprostate matters.
Um, do they need an embolizationahead of time?
You know, there's a lot ofcoordination going involved, but
I think having all the implantsready, have a team, you know,
your, your reps in yourindustry, who you're working
with, make sure they know andplan ahead.
(19:38):
We usually like to meet ahead oftime.
So we're all on the same page,but once you do enough of them
and it becomes routine, everyonekind of knows where you're
going, but again, I would saythe planning is basically the
bone defects where they're at,is there discontinuity
Abductors, um, the primarydiagnosis are the main, main
things that come to my mind whenI think about how to plan it
out.
Joseph M. Schwab (19:59):
And these are mostly gonna be, um, affecting
what you decide to put in orit's gonna affect your surgical
approach or both?
Chris Johnson (20:08):
Approach not as much.
I mean, I think for me, almostalways now we're going to go
anterior.
Unless on the femur side, ifthere's something crazy in the
femur side that might change howI do things.
Um, but if we're focusing juston the pelvis and the astabular
side, I'll pretty much goanteriorly almost every time at
this point.
Um, even body habitus and thelarger patients generally is not
(20:29):
too much of a problem,particularly more in the
extensile approach.
I think if you're doing astandard, um, which we do, You
know, larger patients primaryhips all the time, but I think
it's more challenging trying tosqueeze in a, you know, primary
hip and a bigger person.
They're larger obese person.
It is a little more challenging.
We're actually working on astudy now, and we showed we were
(20:50):
showing the timing how Dallasimpacted our efficiency.
Which did improve ourefficiency, but one of the
biggest factor to the timelength of surgery was the body
habit is so larger, more obesepatients.
So the surgery down, but with amore extensile approach, it's
not as much of an issue becauseyou're, you're, you're opening
up the Ilium, so it's not, youknow, it's not as easy, but it's
(21:11):
not as much of a problem thatmaybe compared to that of a
primary.
my
Joseph M. Schwab (21:15):
So, so we had a debate at the most recent, uh,
annual meeting of the A HFabout, you know, what's the best
surgical incision for anteriorapproach?
Is it the traditional incision,the hooter incision, or is it
the, the bikini incision?
I'm guessing a lot of yourpatients aren't getting bikini
incision.
Is that right?
Chris Johnson (21:33):
no, we think about that.
We talk with our fellowship,particularly, uh, we talked
about bikini incision.
Not one of my partners does abikini incision.
Um, his practice
Joseph M. Schwab (21:41):
For primaries or for,
Chris Johnson (21:43):
primaries.
Yeah.
Uh, but for me, no, I'm doing astandard da and I can extend
approximately if I need to.
So, um, I think there'scertainly some advantages of
bikini.
It's something I think about alot.
Um, for my practice.
I have, I'm choosing thestandard DA approach with the,
and that can extend along theilium if I need to.
Joseph M. Schwab (22:04):
So tell me a little bit about what, what's
your typical, uh, post-opprotocol for these patients?
You've done a, you, you know,they've gotten the screws,
they've gotten, let's say a, amentum with a relatively
standard stem.
Um, and, um, they're gonna needchemo, maybe they need
radiation.
What, what?
Tell me a little bit about whattheir post-op is gonna look
Chris Johnson (22:24):
Yeah, I mean, I usually, as long as there's no
abductor problems, and you know,all that's normal, I let them
go.
You're up and walking rightaway, just like a routine, uh,
routine anterior hip, really.
I just say, progress istolerated, start with a walker.
Um, you know, usually, and thisis the big difference, some of
these people, You know, may havebeen sick for a long time.
(22:44):
They're really deconditioned.
So you should let them go.
They're not going to move tooquick, but some patients, um, it
comes on quick.
They were pretty healthy 3, 4months ago.
And all of a sudden they'rereally quite sick now.
And so they may be, they may beable to recover quicker.
So there's a wide spectrum ofhow the patients present and who
they are and how they wouldrecover compared to that.
Maybe have a primary hip.
(23:05):
Um, and so, you know, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's it's.
And then the key thing isreally, um, we're fortunate.
We have an oncology therapyprogram.
So we have some therapists whoare specialized in oncology.
They do an amazing job with thepatients and they kind of
understand the protocol.
So that's nice.
We don't always do formaltherapy though.
I would say a lot of patientsjust walking like a normal hip.
I don't routinely do standardtherapy.
We let them progress astolerated the oncology ruled.
(23:27):
I kind of field out.
Some people need more help thanothers.
Um, we just, we just let themprogress as tolerated.
Then we do check their woundsquickly.
Um, I like to watch them oneweek and two weeks, particularly
if they're going to be gettinglike...
You're trying to get back onlike a VEGF inhibitor for renal
cell or things like that, whichare bad for wounds.
You know, I make sure the woundsheal.
(23:49):
Once the wound looks good, Isay, okay, fine, go progress to
chemo or radiation or whateveryou want afterwards.
Usually at about the two weekmark, the wound is looking
reasonable.
There's no concerns.
I say, But it's also adiscussion.
Sometimes men are like, oh, acouple more weeks doesn't really
matter.
I'm like, okay, fine.
Let's, let's wait a little bit.
Or if they're like, no, we, weneed to get this person on chemo
as soon as possible.
I'm like, I'll be a little moreaggressive with them.
(24:11):
And, and so reallymultidisciplinary discussion of
Joseph M. Schwab (24:15):
Um, that it seems to me like these patients
are gonna have a significantmedical team around them, much
more so than the average sort ofprimary total hip
Chris Johnson (24:25):
Yeah, I mean, ideally that's the way it should
be.
Um, Yeah, multidisciplinarytrips, chemo, radiation, um,
ortho, we have a palliative careteam as well, so we have a nice
multidisciplinary team to helpguide them through, but every
patient is different.
Many have less resources.
Some come from far away anddon't have a lot of help.
And so it is, it really is caseby case and trying to optimize
(24:45):
it.
But from a standard, you know,from a hip perspective, we let
them go, let them walk, norestrictions, no hip
precautions, weight bear istolerated, you know, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's Um, and I would say they'resomewhat similar to a primary
hip, usually by the six weekmark, I get an x ray, make sure
nothing's moved, make surethey're happy and if they're
doing well, no problems.
I, I stopped to worry aboutOften
Joseph M. Schwab (25:06):
And you've been doing this procedure in
this patient.
Population, roughly how long?
Chris Johnson (25:12):
switch to interior.
So I've been in practice foreight years.
Yeah, I probably switched todoing the acetabular mets
anteriorly maybe about fouryears ago, so halfway through.
Joseph M. Schwab (25:24):
Anything that you've seen in your patients,
um, in terms of long, longerterm outcomes?
Not, not within the first, youknow, six weeks or so, that
indicates to you that this issomething you shouldn't be doing
or you gotta be making somemodifications to it?
Or is this, are, are you seeing,uh, functional outcomes at least
as good as if not better thanwhat you were experiencing
(25:46):
before?
Chris Johnson (25:48):
I would say the main differences from my
perspective, one is the earlyperiod.
The healing process, like youwould expect, even in the
anterior versus posterior inthis, the early period recovery
seems to be better.
I think the biggest advantagefor me is really the reliability
of doing the reconstruction.
do it supine under x-ray, evenusing hip navigation, I feel
(26:11):
very comfortable putting in awell positioned implant,
generally, and giving them asolid reconstruction that I'm,
I'm really happy with.
So, for me, it's more reliable.
And I think generally, like wealways say, which hip approaches
you use, it's the one thatyou're most comfortable doing.
So I think for me, it has becomethat and, and it's, it is more
reliable for me to do it thatway.
(26:33):
Um.
I think the wound issues can bemore challenging, though, like
we've, you know, studies havedocumented a wound, you know,
particularly for biggerpatients.
You can have some wound issuesat the interior approach and
particularly for the sickerpopulation is something to be
aware of.
We typically will use incisionalvacs post-op if they have a
decent body habitus or or ifthey're kind of get significant
(26:57):
chemo or anything that makes mesay, Oh, gosh, this person's
high risk for wound issues.
I'll put it back on them for 2
Joseph M. Schwab (27:04):
Um, and one of the things we've always been
concerned about in the a HF isactually just the education of
anterior approach.
In general, what you're doingkind of takes it to a whole
nother level.
And so a new surgeon coming intopractice who's done an
orthopedic oncology fellowship,wants to start thinking about
doing these complex cases, um,integrating the anterior
(27:25):
approach.
What's your advice for how theycan do that safely?
Chris Johnson (27:31):
you know, I think it's really interesting.
You look at, um, you know,people's perspective on hip hip,
um, approach and what they use.
It's what they're comfortablewith.
It's what they're exposed to.
And so, um, I think for mepersonally, I was lucky that I
got a lot of anterior exposurein residency.
I didn't do a lot of anteriorfellowship, but then as my
practice grew, I becamecomfortable with it.
(27:52):
So it was a natural blend.
And with our fellows, you know,that was one of the reasons we
started the fellowship isbecause we felt like we were
doing a lot of complex stuff.
We had a lot to offer.
It was just a genuine thing todo.
And so I think I think ourfellows are getting a great
experience because they'reseeing a bunch of primaries, but
they're also seeing some prettyunusual or more complex cases of
blind and blending it together.
So I see our fellows.
(28:13):
They're quite used orcomfortable in a standard case
because it's like, wow, we justhad half the pelvis exposed
yesterday and now we're doingthis primary hip like it seems
accessible, but I think I thinkit takes time like anything like
we know there's the learningcurve with anterior approach and
starting with simple things.
I mean, I, I started with justdoing primary anterior hips and
(28:34):
that made me more comfortable.
But then with my practice,there's just an easier
progression to those things.
So I don't start with easythings and like anything and
build up with progression start.
And I would say a big advicewould be learned from your
partners and colleagues.
One of my senior partners does abunch of anterior hips.
He's really, really good at it.
And, um, I learned from him alot, and so I, you know,
implement those into theoncology side, and, and so, you
(28:57):
know, guess one big advice isdon't, you know, be careful of
what you know, you know, learnfrom other people.
Don't be, don't be scared of,uh, don't be scared of not
knowing.
I think just be really open andhonest with people and, and, and
try to learn from people around
Joseph M. Schwab (29:12):
you.
mentioned, um, earlier an areawhere maybe there's not so much
research in long-term outcomes,for instance, in uns cemented
stems in these patients.
Um, let's talk a just a littlebit, um, about research
directions or, or innovationsthat are particularly exciting
to you.
Are there areas you'reinterested in?
Chris Johnson (29:32):
There's so many areas.
I mean, so we're, we, um, aswe're building our program,
we've started a researchinstitute, which is just getting
off the ground.
So we're a lot of work.
I'm doing right now is buildingour, database and infrastructure
and research team because thereare so many areas.
It's I feel really lucky beingon the oncology side and the
arthroplasty side because when Igo to the meetings, know, I can
(29:55):
tell they don't really knowanything about the oncology
side.
And some of the topics I'm like,I'm like, they've talked about
this over here.
But then you go to the oncologyside.
It's just the opposite.
It's like, I'm like, you guys,we've been the hip people know
this a long time ago.
So bring seeing both sides isreally nice because both sides
have great things to add.
So I think that's been helpfulfor me to seeing kind of bring
the hip, the hip and knee sideto the oncology side.
(30:17):
And I think a great example islike, is like, PGI and we PGI
has very poor data.
completely non.
There's no synergy with any ofthe infection data.
Very little synergy.
A lot of anecdotal stuff goingon timeline of antibiotics.
It's a great scenario in whichwe don't have great data.
(30:37):
But on the, and so the head PNEpeople are like, wow, this is
really challenging, which it is,of course.
But on the oncology side, Imean, we have things like giving
chemotherapy to soft tissuesarcoma patients.
I mean, we have horrible datathere and giving someone chemo
is a big deal.
And so like we were used toliving in the world of having
poor data and the key isinformed decision making.
(31:00):
Don't be dogmatic.
Don't act like you know.
The key is to tell patients,Hey, you know, We don't really
know the subject that well.
Here's the availableinformation.
Here's the risk and benefits ofthese 3 approaches.
And you really evidence basedmedicine and informed decision
making is putting the patient'spreference and values 1st, not
yours.
You give them the informationand help them decide where they
(31:22):
want to go with things.
So anyways, I think.
My that's a long answer to.
I think there's a ton of areasof topic.
I think, you know, fixation, thefemur, like, like you said, can
we press fit in these scenarios?
I think you probably can.
Um, I think the stem designshelp a lot.
Like, we're, we're working on astudy now for fractures.
(31:43):
Everyone's the swing of going towhat we should be cementing more
people.
I think probably was a resultof, like, the Prior style
generation of stems, the wedgestems are like log splitters.
Of course, there are some.
Yeah, those, of course, they hadfractures, but with with our,
um, triple taper stems, I don'tthink I don't think we're
seeing.
I mean, I do all I did a 93 yearold 6 weeks ago, and I just saw
(32:06):
him in the office.
Doing great, you know, the doorsee, you know, very thin bone,
all that.
So yeah, there's, there's lotsof opportunities and getting
more synergistic studies, moremultidisciplinary approach.
Um, I think Michelle Garrett.
don't know if you know, she,she, she was the president of
MSTS and she's done a great jobof doing, you know, the, we talk
(32:27):
about the parody trial, thesafety trial.
Now the perform trials comingout, those are all oncology
studies, but they're allmultidisciplinary perspective,
randomized control styles.
Like, so really bringing theworld together to study things,
I think is going to be a huge
Joseph M. Schwab (32:43):
Chris, this has been, um, absolutely
fantastic.
I, I would love to have you comeout to the a HF annual meeting
and maybe show your tripodtechnique and, and maybe some
results of that.
I, I know we've got surgeons outthere who are hungry to see,
maybe not to do oncology cases,but to see the limits of really
what can be done with anteriorapproach, which is, which is one
(33:03):
of the things that I'm hearingyou describe.
So we'd love to have you comeout to Nashville next year.
Chris Johnson (33:08):
Oh yeah.
I'd be happy to be there.
Sounds like a lot of fun.
Joseph M. Schwab (33:11):
Um, and I really appreciate you joining me
on the A HF podcast.
We'll see you soon.
Okay.
Chris Johnson (33:18):
Okay.
Thanks for having me.
Appreciate it.
Joseph M. Schwab (33:21):
Thank you for joining me for this episode of
the A HF Podcast.
We think of the a HF as afamily.
So if you can remember to take amoment to like and subscribe,
you'd be helping us find morepeople just like you to share
our thoughts with.
And as an a HF family member,you can always drop an idea for
a topic or any feedback you likein the comments below.
(33:43):
You can find the A HF podcast onApple Podcasts, Spotify, or in
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation, all one word.
New episodes of the ahf Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(34:06):
happy, healthy, and cancer free.
Hello and welcome to the A HF Podcast.
I'm your host, Joe Schwab.
Today we're joined by Dr.
Chris Johnson, an orthopediconcology surgeon and leader in
complex adult reconstruction.
Dr.
Johnson serves as president ofOrthopedics Northeast, one of
the largest private orthopedicpractices in the Midwest, and
(00:43):
he's based in Fort Wayne,Indiana.
He's also the co-director of theOrtho Northeast Adult
Reconstruction FellowshipProgram and the chair of
orthopedic oncology at theParkview Pacnet Family Cancer
Institute.
Dr.
Johnson has extensive clinicalexpertise in anterior total hip
arthroplasty, complex revisionarthroplasty and orthopedic
(01:06):
oncology.
He not only brings a uniqueperspective to the management of
complex acetabular pathology.
He's an advocate for usinganterior approach for cases
thought to require other typesof exposures.
Today he joins us to discuss anuanced but increasingly
important topic, treatingmetastatic acetabular disease
(01:28):
and doing it through theanterior approach.
Dr.
Johnson, welcome to the A HFPodcast.
Chris Johnson (01:35):
Hey Joe, thanks for having me, excited to be
here, should be fun.
Joseph M. Schwab (01:38):
So tell me a little bit about your background
and maybe a little bit aboutyour current practice setting.
It sounds interesting.
Chris Johnson (01:45):
sure.
I'm, uh, I'm originally fromMichigan and did residency and
Michigan State University andthen did my orthopedic oncology
fellowship at the University ofWashington Medical Center in
Seattle.
And then it came to OrthopedicsNortheast, uh, to start my
practice and, uh, my.
Focus was really on oncology tostart and we built a sarcoma
program and orthopedic oncologyprogram there then our group has
(02:09):
a very high volume jointreplacement center and we're
doing a lot of complex revisionsand sort of disaster plasticity
type cases.
So we started adultreconstruction fellowship as
well.
So I do a lot of jointreplacement and revision as well
as oncology work.
And, um, on the primary side, Ido a lot of anterior hips.
So kind of blending the oncologyside revision side with the
(02:30):
anterior approach.
Joseph M. Schwab (02:31):
Wow.
And so what, uh, what led you toexplore really the use of
anterior approach in sort ofmanaging oncologic conditions?
Chris Johnson (02:42):
well, I was exposed to a lot of anterior
approach and residency, and, um,you know, patients do great.
And then in my own practice, youknow, I have my sort of anterior
primary side, which is reallyquite nice.
You know, quick surgeries,patients go home same day often,
and, uh, outcomes are great.
And then, you know, of course, Ihave the oncology side, and,
and, and, uh, things are morecomplex and challenging.
(03:02):
But the outcomes of anteriorhips are so good, it was, it's
just very natural to startblending that into, uh, more
complex problems.
Joseph M. Schwab (03:10):
Did you find any unique challenges that came
with, um, the orthopediconcology patient population and
anterior approach?
Or did it, was it a prettyseamless transition?
Chris Johnson (03:22):
I.
would say it was kind of anatural progression.
We start, you know, classicallyacid tabular metastatic defects
are taking care of with, youknow, what was called a
Harrington reconstruction, whereyou make multiple incisions, you
open up the ileum and pelvisside.
You also make a second incisionto do a, uh, you know, posture
approach or lateral approach,and then you reconstruct the
acetabulum with some Steinmanpins, and it was a pretty
(03:44):
invasive surgery.
You're taking down abductors.
Sometimes it's a big surgeryand, um, required a lot of
thought.
Once, um, David Geller's groupin the Bronx, they, they
described the tripod techniquefor acetabular defects.
And that really was a gamechanger for us, because once we
started doing that, we have, youknow, a nice multidisciplinary
team.
In our trauma service, westarted doing percutaneous
(04:05):
screws for some more simpleacetabular defects.
And then the natural progressionof the world, if we're doing
these percutaneous screws, it'snot very invasive.
Why don't we do an answer yourapproach with that and start
doing that for some of our askedother mastectomies.
And so we started with smallercases and build it up to even,
you know, you know, bigchallenging cases.
And the answer your approachworks.
Well, we basically now doingmetastatic disease without
(04:25):
cutting any muscle.
Maybe we'll play it, peel offthe TFL off the helium if we
need a cage or something bigger.
Um, but, you know, the patientsare up and walking and a six
weeks.
It's almost like a primary hipfor some of these patients, A
big change from what we weredoing with, you know, more
classic Harrington typereconstructions.
Joseph M. Schwab (04:43):
And let's talk a little bit about how these
patients sort of present oneswho are coming with, you know,
metastatic disease that's aroundthe acetabulum.
How is that?
I mean, how are, how are theygonna end up in your clinic?
What are you gonna see?
What are they gonna tell you?
Chris Johnson (04:58):
Yeah, I mean, they come from all over the
place, generally have a lot ofpain, that's how it was
discovered.
You know, so they generally haveinguinal pain, similar to an
arthritic patient.
You're going to have groin painor inguinal pain because the hip
joint is, is, is, um, you know,having problems.
And then they'll come in frommedical oncology, they'll come
in from other orthopedic doctorsall over the place.
And then, um, Each case isunique, you know, the size of
(05:19):
the defect, the primary cancer,whether it's lymphoma versus
renal cell, two totallydifferent things.
Renal cell can be much morechallenging, bleeding,
progression of disease, um, orother things like prostate
cancer, breast cancer.
Breast cancer can be moresensitive to radiation, so
really the specific diagnosis isvery important to which type of
(05:40):
metastatic disease it is.
Um, and then once they, oncethey present and we have them,
we really, we get advancedimaging like a CT scan to sort
of see the 3D defect to thenplan ahead of how we're gonna,
if we need to, how we're goingto reconstruct it.
Joseph M. Schwab (05:54):
Mm-hmm.
And so how do you decide on whoyou're gonna operate?
Uh, you know, who's a goodcandidate for surgery for this
particular surgery?
Chris Johnson (06:03):
I mean, AST is a, challenging problem and
generally should requiremultidisciplinary approach,
medical oncology, radiationoncology, orthopedic oncology,
I'm a big believer in informeddecision making, talking to the
patients and family, giving themthe risk and benefits of each
scenario.
And these are big surgeriesshould be last resort.
If you can get away withradiation or non operative
things first, certainlyreasonable to try, but I would
(06:25):
say anecdotally, in my practice,we've got a little more
aggressive of surgery becausewe're doing an anterior
approach.
We're doing percutaneous screws.
It's not as big of a dealanymore.
And so we can be a little moreaggressive with getting surgery
done and people are happy andyou know, they, they get up and
walking.
All these patients come in, theyare non ambulatory, cannot walk
at all severe pain.
You know, many of them arewalking the day of surgery.
(06:45):
And so.
Um, but informant says you'remaking it a little more
challenges than a primary hip orrevision hip because you have to
deal with chemotherapy.
They're probably, you know,higher host.
See, basically, they're onchemotherapy.
They're immunocompromised andthen fixation, you know, we
can't utilize horse metal asmuch because we may not have
good in growth, which you canwith TM in certain scenarios,
(07:07):
but you're usually more cementand cement fixation compared to
a standard revision.
So a little bit unique in thatregard.
Joseph M. Schwab (07:15):
So it sounds like anterior, the using
anterior approach has allowedyou to sort of expand your
surgical indications in thispopulation at least a little
bit.
Chris Johnson (07:23):
think so.
I think for me personally, I wasa little more conservative with
a more classic Harringtonapproach because it was such a
big surgery.
We really, you know, it takestime to heal.
Someone has metastatic lungcancer, for example, and maybe
their prognosis, their lifespan,maybe a year or less, and
they're going to spend three tofour months recovering.
It's like, I don't know.
You know, what is worth?
What's the appropriate boundary?
Again, family discussion withthe anti approach.
(07:45):
You know, we're getting themhealing faster.
It's a little quicker.
You know, in 6 weeks, I feellike they're usually generally
pretty happy and doing prettyrelatively well.
So you can get him healedquicker so that you have to
worry as much about the timelinedecision making.
Joseph M. Schwab (08:01):
So when somebody shows up, I'm, I'm
really familiar with whensomebody shows up with arthritis
in their hip, I know what thegoals of my operation are gonna
be.
I mean, I, I, I know I want toget them back up and
functioning, get'em playingpickleball, get'em playing golf,
doing all those sorts of things.
When you're treating these typesof lesions in the
Chris Johnson (08:19):
hmm.
Joseph M. Schwab (08:20):
um, are, are your primary surgical goals
different?
What are you looking to achieve?
Chris Johnson (08:27):
That's a great question.
The really the primary focus oftreating anybody with menistic
disease, whether it's in theacetabulum, the femur anywhere
is immediate weight bearing.
Ambulation and function, becausethese patients may have a
shorter lifespan.
You want to get them going.
They're often gettingchemotherapy.
So if they're stuck in a bed forsix weeks, it's not very good.
So they need to be up andwalking to tolerate chemotherapy
(08:49):
and subsequent treatments andalso quality of life.
So the main goal is immediateweight bearing.
Unlike some revision scenarioswhere you may.
You know, let's say like a, uh,pelvic discontinuity and maybe
you're doing a tri-flange.
You might protect their weightbearing for a little while.
Let's try to get ingrowth in theimplant, etc.
In this case, we don't reallyhave that time.
We don't have that luxury oftime, so we gotta get immediate
(09:10):
weight bearing right away.
So that's the big difference, Iwould say, is we want to allow
for immediate ambulation.
So cement fixation in certainscenarios and, and try and get
them going.
Joseph M. Schwab (09:20):
And so let's talk a little bit about the
technique.
I mean, you mentioned the tripodtechnique.
Tell me a little bit, can yougimme a brief description of
what it, what it is, what itlooks like?
Chris Johnson (09:30):
so the tripod technique is much.
It's really the percutaneousscrews for acetabular fractures.
It's really originally describedby the trauma world um, then
when David Geller's group kindof combined it brought to the
ortho oncology world, which is,you know, a great concept.
I showed it to some of ourtrauma colleagues and say, Hey,
(09:50):
can you guys do this?
And they're like, Yeah, we dothis all the time for geriatric
patients.
Falls and fractures and like,okay, well, let's let's start
doing with these and I'm luckyto have a great team.
So, um, our trauma service isvery good doing per screws.
So we started doing them andthey do them in like 30 minutes.
I mean, it's really quick andeasy.
They basically get certainspecific views.
You're basically putting screwsthrough the poster column.
(10:14):
anterior column and then the LC2screw like in the trauma world.
So you're really creating atripod to reinforce the
acetabulum similar to what aHarrington reconstruction is
doing by putting K wires downthrough the ileum trying to
basically rebarb the acetabulumto put cement into it.
This is doing the same thing,but with three small incision
percutaneous incisions underfluoroscopic guidance.
(10:37):
And you're basically puttinglong screws that go into good
bone through the You know, thecancer and defect into good bone
again because they're longscrews and that allows a less
invasive, quick and precise wayto or rebarb the acetabulum to
allow for subsequent andoriginally described for just
(10:58):
the screws only.
But you could.
I think the original study had20 patients, but they said you
could augment or, you know,convert to a total hip easily.
And so we started doing screwswith the tripod technique, and
then in cases who had a lot ofdefects around the acetabulum,
then, then adding, adding in atotal hip.
And we started with posteriorapproach, because that's what I
was comfortable doing in morecomplex things.
And as I went on, we evolved tothe
Joseph M. Schwab (11:20):
So when you're actually doing the
reconstruction, they've gottheir screws in place.
Um, are, are they doing any, sofirst of all, um, when they're
getting their screws put in, arethey doing any percutaneous
cement application at the sametime or just the screw?
Chris Johnson (11:35):
you could in cases in which there are
different products out therewhere you could put screws that
have cement.
We have not been doing it.
And some places do describethat.
That's certainly an option.
What we typically do if it's ifit's a screw only case, we put
the screws in and see how theydo.
If it's screws and total hip, weput the screws in and then I'll
open it up to the anteriorapproach.
And it really depends again.
(11:57):
Each case is different where thedefect is, what type of cancer
it is.
We open up through an antiapproach.
What's obviously nice about theanti approach is the S tablet
exposures.
So nice.
There's a pine easy X ray youcan see the tablet really,
really well.
So it's just so convenient.
And then we'll remove the tumor,because these are more
palliative cases, we're notdoing a wide excision, we're
(12:18):
doing intralesional excisions,removing the bone, often burr
down to help, to, as best wecan, down to normal bone, so
you, then you see the remainingdefect.
And then at that case, youusually have a pretty good idea
going into the size, if there'sdiscontinuity, etc.
Do you need to augment with thecage?
Are you just doing the bigshell?
Are you cementing it?
We do a lot of, um, you know,cemented dual mobility liners,
(12:40):
where we just cement them in anddo that anteriorly.
Um, if we need constraint ornot, you know, do they have, you
know, sometimes they need a PFR,maybe the proximal femur is
gone.
So really each case is unique,assessing where the defects are,
what the challenges are, and howyou're gonna, you know,
reconstruct it most optimally.
Joseph M. Schwab (12:57):
So, um, we actually got introduced through,
um, a mutual acquaintance thatwe know at at Johnson Johnson, j
and j Med Tech.
DePuy Synthes, Johnson andJohnson.
Um, are those the implantsystems that you typically use,
or what are, what kind ofconstructs are you typically
using?
It's okay to use brand names ifyou want to.
It's, uh, you just, or are youusing a variety of, uh, of
(13:19):
items?
Chris Johnson (13:21):
used a variety.
I have used a lot of J&J.
Thank you.
Um, they're, um, Bimentum Cup, Iuse a lot.
I think it's very, very, so I'm,you know, do a lot of J&J
anterior hips.
The actus is a great stem, soit's super easy.
And we're using their valusnavigation with these two.
So it's another thing comparedto poster approach Harrington
where you're trying to, youknow, imagine putting a cup in
(13:42):
with a huge hole.
I mean, it is, no one can bethat precise at but you get to
do it on the anterior perchunder fluoro.
I'm putting in a cemented cupunder, under VHN or under
navigation assistance forprinting these cuffs in a
pretty, you know, relativelyprecise way.
So because of all that, I tendedto use the J&J, Bimentum, which
(14:03):
is a cemented single dualmobility liner, and then I just
do the femur like normal, andthen it's pretty simple.
we have you some like a cage hasbecome less, less common.
A lot of companies are gettingrid of cages, which would prefer
they didn't because I understandthat in a revision setting where
(14:24):
you're trying to get on growthmakes sense.
You know, porous metals, customimplants, augments, all that
stuff makes total sense in astandard revision.
Aseptic loosening, you're tryingto get osseo integration.
So the implants last in thecancer world, you don't
necessarily have that.
You don't have the luxury oftime.
So, cages can help, certainly,oncology cases because you can,
(14:45):
you do the tripod to help getrid of discontinuity, reinforce
the acetabulum, but then you canbridge the defect even more so
if there's more massive boneloss with, um, with some cages.
And so, um, we have used SmithNephew for certain cases because
they still have a decent, nicecage system.
So, depending on what I need,I'll adjust.
Joseph M. Schwab (15:05):
Yeah.
Um, and I was gonna ask, I mean,because most of these, because
this patient populationspecifically, you're talking
about metastatic disease aroundthe acetabulum, you're able to
use a, a pretty standard primarystem.
I mean, you mentioned the Actisstem, right?
It, it's, most of the timeyou're gonna be putting in
something fairly basic likethat.
Chris Johnson (15:25):
a really good question.
So I think that's somethingthat's not been studied well,
and it's a little anecdotal.
Historically, in the oncologyworld, you cement everything
and, you know, someone has apristine femur, but has
acetabular menistic disease.
Do you need to cement the femur?
I don't know.
I mean, they might getradiation.
So, will the radiation impactthe young growth on the femoral
(15:46):
side?
Is there a higher risk ofloosening?
Because they get radiation, evenif they have no disease there?
Of course if they have diseasein the bone, in the femur, I'm
gonna cement.
But if they have a pristine,normal femur, I haven't
breastfed anymore because, um,know, I haven't had a lot of
problems with loosening theactive.
I have a lot of experience withthe active stem and a triple
(16:07):
taper stem.
It works well and there is somerisk, you know, B.
C.
I.
S.
Bone implant syndrome.
You know, people always talkabout should you cement or not
in the in the primary settingand all these things.
But in my mind, this is just myperspective.
You know, how many fractureswould you accept?
Or how many loosenings would youaccept for one catastrophic
(16:27):
BCIS?
And so, in the oncology world,we cement more, and I have seen,
you know, a handful of patientshave problems with cementing.
It is a big deal.
And so, if you can get away withpress fitting, I think it's, it
works well.
So, I have been more and moreaggressive in my practice with
press fitting a standard stem insomeone who has metastatic
disease in the last tabulum, andhaven't really had any problems
Joseph M. Schwab (16:48):
So you've mentioned some of the advantages
that at least you've seen inbeing able to do some of this
through an anterior approach.
Are there any technicalchallenges that you run into in
this patient population orexposure?
Uh, exposure challenges forthese more complex
reconstructions.
Chris Johnson (17:05):
think on the acetabular side, it's honestly
easier.
Um, when I compare, I think partof it is the experience thing,
and just the fear.
When you do something new in alearning curve, you're worried
about making mistakes and doingsomething wrong.
And as you get through practice,you start to gain confidence and
try, you know, just try to bereasonable and do the right
thing.
(17:25):
When I compare it to doing a,say, a Tri-Flandre custom
implant on a revision settingand a post-G approach, I think
it's a lot easier.
And which we've done quite a bitof those and have good
experience with that.
It's still, there's still somechallenges exposing the ileum
without hurting the abductors,all those things.
With the anti-approach, you'resupine, you can peel off the
TFL, and you can expose thewhole ileum extremely easily.
(17:48):
And then repairs really nicely,you repair it right back to the
top of the ileum.
It's a really nice exposure.
I think, I remember we weredoing, once we were starting to
think about these things, wewere doing a course for J&J
actually, and we had someFellows with us and we were
doing just some cadaver labs andwe were exploring like, can we
really do a tri flangeinteriorly?
Can we put cages on interiorly?
(18:09):
And it was so easy and I waslike, it was for me.
I was a big confidence boosterbecause I was trying to teach
people what to do, but I wasreally experimenting myself and
I'm like, wow, I can, I can putmy finger in this attic notch
and feel the bottom of theissue.
It's really easy.
I mean, if you extend theincision approximately over the
iliac brim and then peel off theTFL, it's one big sleeve and the
(18:29):
whole lateral pelvis is rightthere.
It's pretty remarkable.
Joseph M. Schwab (18:33):
Yeah, that's, uh, so how do you go about, you
mentioned actually usingintraoperatively, using ves for
cup positioning and things likethat, or, you know, using some
sort of intraoperative uh,technology.
How do you plan for these cases?
What, I mean, what, what are youusing to, to come up with your,
I'm assuming there's plans Athrough Z right?
Chris Johnson (18:54):
Yeah, we're, I mean, we're lucky that we have
an institution where we haveeverything on the shelf.
So, I mean, I pretty much, Idon't have to worry too much.
And we have we're busy and sothe teams are used to what we're
doing.
We're not doing it's not newevery time.
But yes, no doubt.
You have to plan for everything.
Um, I'm a planner.
I like to think ahead.
And, um, but yes, sort of astepwise approach where the
(19:16):
defects their discontinuity.
the cancer, what's the primarydiagnosis?
Renal cell versus breast versusprostate matters.
Um, do they need an embolizationahead of time?
You know, there's a lot ofcoordination going involved, but
I think having all the implantsready, have a team, you know,
your, your reps in yourindustry, who you're working
with, make sure they know andplan ahead.
(19:38):
We usually like to meet ahead oftime.
So we're all on the same page,but once you do enough of them
and it becomes routine, everyonekind of knows where you're
going, but again, I would saythe planning is basically the
bone defects where they're at,is there discontinuity
Abductors, um, the primarydiagnosis are the main, main
things that come to my mind whenI think about how to plan it
out.
Joseph M. Schwab (19:59):
And these are mostly gonna be, um, affecting
what you decide to put in orit's gonna affect your surgical
approach or both?
Chris Johnson (20:08):
Approach not as much.
I mean, I think for me, almostalways now we're going to go
anterior.
Unless on the femur side, ifthere's something crazy in the
femur side that might change howI do things.
Um, but if we're focusing juston the pelvis and the astabular
side, I'll pretty much goanteriorly almost every time at
this point.
Um, even body habitus and thelarger patients generally is not
(20:29):
too much of a problem,particularly more in the
extensile approach.
I think if you're doing astandard, um, which we do, You
know, larger patients primaryhips all the time, but I think
it's more challenging trying tosqueeze in a, you know, primary
hip and a bigger person.
They're larger obese person.
It is a little more challenging.
We're actually working on astudy now, and we showed we were
(20:50):
showing the timing how Dallasimpacted our efficiency.
Which did improve ourefficiency, but one of the
biggest factor to the timelength of surgery was the body
habit is so larger, more obesepatients.
So the surgery down, but with amore extensile approach, it's
not as much of an issue becauseyou're, you're, you're opening
up the Ilium, so it's not, youknow, it's not as easy, but it's
(21:11):
not as much of a problem thatmaybe compared to that of a
primary.
my
Joseph M. Schwab (21:15):
So, so we had a debate at the most recent, uh,
annual meeting of the A HFabout, you know, what's the best
surgical incision for anteriorapproach?
Is it the traditional incision,the hooter incision, or is it
the, the bikini incision?
I'm guessing a lot of yourpatients aren't getting bikini
incision.
Is that right?
Chris Johnson (21:33):
no, we think about that.
We talk with our fellowship,particularly, uh, we talked
about bikini incision.
Not one of my partners does abikini incision.
Um, his practice
Joseph M. Schwab (21:41):
For primaries or for,
Chris Johnson (21:43):
primaries.
Yeah.
Uh, but for me, no, I'm doing astandard da and I can extend
approximately if I need to.
So, um, I think there'scertainly some advantages of
bikini.
It's something I think about alot.
Um, for my practice.
I have, I'm choosing thestandard DA approach with the,
and that can extend along theilium if I need to.
Joseph M. Schwab (22:04):
So tell me a little bit about what, what's
your typical, uh, post-opprotocol for these patients?
You've done a, you, you know,they've gotten the screws,
they've gotten, let's say a, amentum with a relatively
standard stem.
Um, and, um, they're gonna needchemo, maybe they need
radiation.
What, what?
Tell me a little bit about whattheir post-op is gonna look
Chris Johnson (22:24):
Yeah, I mean, I usually, as long as there's no
abductor problems, and you know,all that's normal, I let them
go.
You're up and walking rightaway, just like a routine, uh,
routine anterior hip, really.
I just say, progress istolerated, start with a walker.
Um, you know, usually, and thisis the big difference, some of
these people, You know, may havebeen sick for a long time.
(22:44):
They're really deconditioned.
So you should let them go.
They're not going to move tooquick, but some patients, um, it
comes on quick.
They were pretty healthy 3, 4months ago.
And all of a sudden they'rereally quite sick now.
And so they may be, they may beable to recover quicker.
So there's a wide spectrum ofhow the patients present and who
they are and how they wouldrecover compared to that.
Maybe have a primary hip.
(23:05):
Um, and so, you know, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's it's.
And then the key thing isreally, um, we're fortunate.
We have an oncology therapyprogram.
So we have some therapists whoare specialized in oncology.
They do an amazing job with thepatients and they kind of
understand the protocol.
So that's nice.
We don't always do formaltherapy though.
I would say a lot of patientsjust walking like a normal hip.
I don't routinely do standardtherapy.
We let them progress astolerated the oncology ruled.
(23:27):
I kind of field out.
Some people need more help thanothers.
Um, we just, we just let themprogress as tolerated.
Then we do check their woundsquickly.
Um, I like to watch them oneweek and two weeks, particularly
if they're going to be gettinglike...
You're trying to get back onlike a VEGF inhibitor for renal
cell or things like that, whichare bad for wounds.
You know, I make sure the woundsheal.
(23:49):
Once the wound looks good, Isay, okay, fine, go progress to
chemo or radiation or whateveryou want afterwards.
Usually at about the two weekmark, the wound is looking
reasonable.
There's no concerns.
I say, But it's also adiscussion.
Sometimes men are like, oh, acouple more weeks doesn't really
matter.
I'm like, okay, fine.
Let's, let's wait a little bit.
Or if they're like, no, we, weneed to get this person on chemo
as soon as possible.
I'm like, I'll be a little moreaggressive with them.
(24:11):
And, and so reallymultidisciplinary discussion of
Joseph M. Schwab (24:15):
Um, that it seems to me like these patients
are gonna have a significantmedical team around them, much
more so than the average sort ofprimary total hip
Chris Johnson (24:25):
Yeah, I mean, ideally that's the way it should
be.
Um, Yeah, multidisciplinarytrips, chemo, radiation, um,
ortho, we have a palliative careteam as well, so we have a nice
multidisciplinary team to helpguide them through, but every
patient is different.
Many have less resources.
Some come from far away anddon't have a lot of help.
And so it is, it really is caseby case and trying to optimize
(24:45):
it.
But from a standard, you know,from a hip perspective, we let
them go, let them walk, norestrictions, no hip
precautions, weight bear istolerated, you know, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's, it's, it's, it's, it's,it's, it's, it's, it's, it's,
it's Um, and I would say they'resomewhat similar to a primary
hip, usually by the six weekmark, I get an x ray, make sure
nothing's moved, make surethey're happy and if they're
doing well, no problems.
I, I stopped to worry aboutOften
Joseph M. Schwab (25:06):
And you've been doing this procedure in
this patient.
Population, roughly how long?
Chris Johnson (25:12):
switch to interior.
So I've been in practice foreight years.
Yeah, I probably switched todoing the acetabular mets
anteriorly maybe about fouryears ago, so halfway through.
Joseph M. Schwab (25:24):
Anything that you've seen in your patients,
um, in terms of long, longerterm outcomes?
Not, not within the first, youknow, six weeks or so, that
indicates to you that this issomething you shouldn't be doing
or you gotta be making somemodifications to it?
Or is this, are, are you seeing,uh, functional outcomes at least
as good as if not better thanwhat you were experiencing
(25:46):
before?
Chris Johnson (25:48):
I would say the main differences from my
perspective, one is the earlyperiod.
The healing process, like youwould expect, even in the
anterior versus posterior inthis, the early period recovery
seems to be better.
I think the biggest advantagefor me is really the reliability
of doing the reconstruction.
do it supine under x-ray, evenusing hip navigation, I feel
(26:11):
very comfortable putting in awell positioned implant,
generally, and giving them asolid reconstruction that I'm,
I'm really happy with.
So, for me, it's more reliable.
And I think generally, like wealways say, which hip approaches
you use, it's the one thatyou're most comfortable doing.
So I think for me, it has becomethat and, and it's, it is more
reliable for me to do it thatway.
(26:33):
Um.
I think the wound issues can bemore challenging, though, like
we've, you know, studies havedocumented a wound, you know,
particularly for biggerpatients.
You can have some wound issuesat the interior approach and
particularly for the sickerpopulation is something to be
aware of.
We typically will use incisionalvacs post-op if they have a
decent body habitus or or ifthey're kind of get significant
(26:57):
chemo or anything that makes mesay, Oh, gosh, this person's
high risk for wound issues.
I'll put it back on them for 2
Joseph M. Schwab (27:04):
Um, and one of the things we've always been
concerned about in the a HF isactually just the education of
anterior approach.
In general, what you're doingkind of takes it to a whole
nother level.
And so a new surgeon coming intopractice who's done an
orthopedic oncology fellowship,wants to start thinking about
doing these complex cases, um,integrating the anterior
(27:25):
approach.
What's your advice for how theycan do that safely?
Chris Johnson (27:31):
you know, I think it's really interesting.
You look at, um, you know,people's perspective on hip hip,
um, approach and what they use.
It's what they're comfortablewith.
It's what they're exposed to.
And so, um, I think for mepersonally, I was lucky that I
got a lot of anterior exposurein residency.
I didn't do a lot of anteriorfellowship, but then as my
practice grew, I becamecomfortable with it.
(27:52):
So it was a natural blend.
And with our fellows, you know,that was one of the reasons we
started the fellowship isbecause we felt like we were
doing a lot of complex stuff.
We had a lot to offer.
It was just a genuine thing todo.
And so I think I think ourfellows are getting a great
experience because they'reseeing a bunch of primaries, but
they're also seeing some prettyunusual or more complex cases of
blind and blending it together.
So I see our fellows.
(28:13):
They're quite used orcomfortable in a standard case
because it's like, wow, we justhad half the pelvis exposed
yesterday and now we're doingthis primary hip like it seems
accessible, but I think I thinkit takes time like anything like
we know there's the learningcurve with anterior approach and
starting with simple things.
I mean, I, I started with justdoing primary anterior hips and
(28:34):
that made me more comfortable.
But then with my practice,there's just an easier
progression to those things.
So I don't start with easythings and like anything and
build up with progression start.
And I would say a big advicewould be learned from your
partners and colleagues.
One of my senior partners does abunch of anterior hips.
He's really, really good at it.
And, um, I learned from him alot, and so I, you know,
implement those into theoncology side, and, and so, you
(28:57):
know, guess one big advice isdon't, you know, be careful of
what you know, you know, learnfrom other people.
Don't be, don't be scared of,uh, don't be scared of not
knowing.
I think just be really open andhonest with people and, and, and
try to learn from people around
Joseph M. Schwab (29:12):
you.
mentioned, um, earlier an areawhere maybe there's not so much
research in long-term outcomes,for instance, in uns cemented
stems in these patients.
Um, let's talk a just a littlebit, um, about research
directions or, or innovationsthat are particularly exciting
to you.
Are there areas you'reinterested in?
Chris Johnson (29:32):
There's so many areas.
I mean, so we're, we, um, aswe're building our program,
we've started a researchinstitute, which is just getting
off the ground.
So we're a lot of work.
I'm doing right now is buildingour, database and infrastructure
and research team because thereare so many areas.
It's I feel really lucky beingon the oncology side and the
arthroplasty side because when Igo to the meetings, know, I can
(29:55):
tell they don't really knowanything about the oncology
side.
And some of the topics I'm like,I'm like, they've talked about
this over here.
But then you go to the oncologyside.
It's just the opposite.
It's like, I'm like, you guys,we've been the hip people know
this a long time ago.
So bring seeing both sides isreally nice because both sides
have great things to add.
So I think that's been helpfulfor me to seeing kind of bring
the hip, the hip and knee sideto the oncology side.
(30:17):
And I think a great example islike, is like, PGI and we PGI
has very poor data.
completely non.
There's no synergy with any ofthe infection data.
Very little synergy.
A lot of anecdotal stuff goingon timeline of antibiotics.
It's a great scenario in whichwe don't have great data.
(30:37):
But on the, and so the head PNEpeople are like, wow, this is
really challenging, which it is,of course.
But on the oncology side, Imean, we have things like giving
chemotherapy to soft tissuesarcoma patients.
I mean, we have horrible datathere and giving someone chemo
is a big deal.
And so like we were used toliving in the world of having
poor data and the key isinformed decision making.
(31:00):
Don't be dogmatic.
Don't act like you know.
The key is to tell patients,Hey, you know, We don't really
know the subject that well.
Here's the availableinformation.
Here's the risk and benefits ofthese 3 approaches.
And you really evidence basedmedicine and informed decision
making is putting the patient'spreference and values 1st, not
yours.
You give them the informationand help them decide where they
(31:22):
want to go with things.
So anyways, I think.
My that's a long answer to.
I think there's a ton of areasof topic.
I think, you know, fixation, thefemur, like, like you said, can
we press fit in these scenarios?
I think you probably can.
Um, I think the stem designshelp a lot.
Like, we're, we're working on astudy now for fractures.
(31:43):
Everyone's the swing of going towhat we should be cementing more
people.
I think probably was a resultof, like, the Prior style
generation of stems, the wedgestems are like log splitters.
Of course, there are some.
Yeah, those, of course, they hadfractures, but with with our,
um, triple taper stems, I don'tthink I don't think we're
seeing.
I mean, I do all I did a 93 yearold 6 weeks ago, and I just saw
(32:06):
him in the office.
Doing great, you know, the doorsee, you know, very thin bone,
all that.
So yeah, there's, there's lotsof opportunities and getting
more synergistic studies, moremultidisciplinary approach.
Um, I think Michelle Garrett.
don't know if you know, she,she, she was the president of
MSTS and she's done a great jobof doing, you know, the, we talk
(32:27):
about the parody trial, thesafety trial.
Now the perform trials comingout, those are all oncology
studies, but they're allmultidisciplinary perspective,
randomized control styles.
Like, so really bringing theworld together to study things,
I think is going to be a huge
Joseph M. Schwab (32:43):
Chris, this has been, um, absolutely
fantastic.
I, I would love to have you comeout to the a HF annual meeting
and maybe show your tripodtechnique and, and maybe some
results of that.
I, I know we've got surgeons outthere who are hungry to see,
maybe not to do oncology cases,but to see the limits of really
what can be done with anteriorapproach, which is, which is one
(33:03):
of the things that I'm hearingyou describe.
So we'd love to have you comeout to Nashville next year.
Chris Johnson (33:08):
Oh yeah.
I'd be happy to be there.
Sounds like a lot of fun.
Joseph M. Schwab (33:11):
Um, and I really appreciate you joining me
on the A HF podcast.
We'll see you soon.
Okay.
Chris Johnson (33:18):
Okay.
Thanks for having me.
Appreciate it.
Joseph M. Schwab (33:21):
Thank you for joining me for this episode of
the A HF Podcast.
We think of the a HF as afamily.
So if you can remember to take amoment to like and subscribe,
you'd be helping us find morepeople just like you to share
our thoughts with.
And as an a HF family member,you can always drop an idea for
a topic or any feedback you likein the comments below.
(33:43):
You can find the A HF podcast onApple Podcasts, Spotify, or in
any of your favorite podcastapps, as well as in video form
on YouTube slash at anterior hipfoundation, all one word.
New episodes of the ahf Podcastcome out on Fridays.
I'm your host, Joe Schwab,asking you to keep those hips
(34:06):
happy, healthy, and cancer free.
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